For satisfactory long-term results form use of left ventricular auxiliary devices, an enormous role is played by their correct positioning during surgery and maintenance of this position for the life of the patient (Adamson R. M., Mangi A. A., Kormos R. L., Farrar D. J., and Dembitsky W. P. Principles of HeartMate II Implantation to Avoid Pump Malposition and Migration. J Card Surg 2015; 30:296-299; doi: 10.1111/jocs.12478).
According to the 8th Annual Report INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support (Kirklin J. K., Pagani F. D., Kormos R. L., Stevenson L. W., Blume E. D., Myers S. L., Miller M. A., Baldwin J. T., Young J. B., and Naftel D. C. Eighth annual INTERMACS report: Special focus on framing the impact of adverse events. J Heart Lung Transplant 2017; 36:1080-1086), the data base of which does not include HeartMate III, some of the frequent complications are:                blood flow (16.24% in the first 3 months post surgery);        infection (13.63%).        
At the same time, for practically 50% of patients, artificial left ventricles are planned in the capacity of “destination therapy” (permanent treatment).
The basic reasons for a lethal outcome, according to the INTERMACS Report, are neurologic dysfunctions, polyorganic insufficiency, infections, disruption of function of the devices, and insufficiency of the right ventricle.
A method is known for implantation of the left ventricular mechanical assist device HeartWare, which includes the following operation stages of use [HeartWare Ventricular Assist System Instructions for Use. HeartWare, Inc. Authorized 2009]. The HeartWare device is implanted intrapericardially. Choose the site of implantation of the inflow cannula somewhat anteriorly to the apex of the left ventricle and roughly 2 cm laterally to the anterior interventricular branch. The inflow cannula must be positioned in the direction of the mitral valve and in parallel to the interventricular septum. The sewing cuff is fixed to the myocardium using 8-12 2-0 polypropylene sutures with synthetic pledges. Said sutures do not reach the left ventricular chamber. [Krabatsch T., Drews T., Potapov E., Weng Y., Pasic M., Hetzer R. Different surgical strategies for implantation of continuous-flow VADs—Experience from Deutsches Herzzentrum Berlin. Ann Cardiothorac Surg 2014; 3(5):472-474; doi: 10.3978/j.issn.2225-319X.2014.09.06], that is, they are positioned intramyocardially. Then a crosswise incision is made of the myocardium with a scalpel and further a circular opening is made with a special instrument. A visual inspection is made of the left ventricular chamber to eliminate possible causes of obstruction of the inflow cannula (thrombi etc.). The latter is joined to the sewing cuff. Using a wrench, the sewing cuff is tightened around the cannula until there is a “click.” An anastomosis is formed between the outflow graft and the ascending aorta. Device driveline tunneling, air embolism prophylaxis, an increase in the speed of the HeartWare device, and disconnection of the cardiopulmonary bypass (CPB) are carried out.
One drawback of the known method of HeartWare implantation is that the anatomic selection of the region of implantation of the inflow cannula (orientation relative to the anterior interventricular branch and the cardiac apex in cm). Determining the location should also be done under the observation of transesophageal echo cardiography, since heart dimensions can vary among different patients, and thus also the distance of the incision from the anterior interventricular branch and cardiac apex. Second, when “sew then cut” technique is used, it is technically inconvenient to make the revision of the left ventricular chamber to check the presence of possible inflow cannula obstruction factors. Third, considering the fact that the sutures for suturing the sewing cuff are disposed intramyocardially, there are potential risks of obstruction of the inflow cannula by the margins of the myocardium from the intraventricular chamber not covered by the sutures.
A method is known for implanting the HeartMate II left ventricular mechanical assist device, which includes preperitoneal and intraperitoneal placement of a pump [1) HeartMate II LVAS.
Sistema podderzhki levogo zheludochka. Instruktsii po primeneniyu. Thoratec Corporation, 2005. 2) Slaughter M. S., Pagani F. D., Rogers J. G., Miller L. W., Sun B., Russell S. D., Starling R. C., Chen L., Boyle A. J., Chillcott S., Adamson R. M., Blood M. S., Camacho M. T., Idrissi K. A., Petty M., Sobieski M., Wright S., Myers T. J., and Farrar D. J., for the HeartMate II Clinical Investigators. Clinical management of continuous-flow left ventricular assist devices in advanced heart failure. J Heart Lung Transplant 2010; 29:S1-S39]. With preperitoneal positioning, a pouch for the device is created superiorly to the posterior portion of the insertion of the rectus abdominis muscle and the transverse fascia and inferiorly to the rectus abdominis and the internal oblique muscles. This method can be more preferable for patients who already had surgical operations in the abdominal region or for patients with a short torso. The device is placed beyond the limits of the internal organs of the abdominal chamber, where intestinal adhesions are unlikely. With intra-abdominal placement the pump is inserted into the abdomen to the left superior abdominal quadrant. This method may be preferable for a patient with malnutrition, for whom the risk of pump erosion through the skin is significant. In addition, correct tunneling of the device driveline may prove impossible for this group of patients. After preparation of the pump pouch, the driveline is tunneled. An 8-mm skin coring punch is used to perforate the skin. A site for the cylindrical incision is chosen that is anterior to the apex and a few centimeters to the side of the left anterior descending artery. A revision of the left ventricular chamber is made.Secure the sewing ring cuff with at least 12 horizontal mattress sutures of nearly the full thickness at a distance of approximately 1.5 cm from the edge of the incision. Some literature sources describe the following technique for implantation of the sewing cuff of the device HeartMate II [1) Pawale A., Plotkina I., Anyanwu A. C. Technique for implantation of HeartMate II left ventricular assist device with concurrent mitral and tricuspid valve repair. Ann Cardiothorac Surg 2014; 3(5):532-534; doi: 10.3978/j.issn.2225-319X.2014.08.11. 2) Soleimani B., Stephenson E. R., Pae W. Technique for insertion of HeartMate II left ventricular assist device inflow cannula. Ann Thorac Surg 2011:91:2001-2002]. Twelve “pi-shaped” sutures of Ethibond 3-0 with synthetic pledgets are placed. The first needle passes through the entire thickness of the myocardium at a distance of 1.5 cm from the edge of the incision. Then this same needle is passed back at a distance of 2-3 mm from the edge of the incision from the endocardium to the epicardium. According to the authors, this technique makes it possible to reduce the incidence of development of postoperative bleeding. The outflow cannula is joined to the apical sewing ring and reinforced with ligatures. At its proximal end, the sealed drainage implant is connected to the drainage bend of the pump. An anastomosis is created between the outflow graft and the ascending aorta. De-airing is carried out, the HeartMate II device is activated and the CPB pump is turned off.
Defects of the pre-abdominal placement include the risk of development of a pouch hematoma, infections of the pouch and the outlet region, wound dehiscence and erosion of the skin over the implanted device. Possible complications of the intra-abdominal method of implantation may include membrane hernia of the pericardium, wound dehiscence, abdominal (intestinal) adhesions, intestinal blockage, erosion of the stomach, the rectum, and liver and internal organs of the abdominal chamber. The use of the skin coring punch can be a more traumatic method, which can lead to unsatisfactory healing of the wound surface. The device has a flexible silicon sleeve, which during creation of a small pump pouch may lead to its angulation, this causing an obstruction at the level of the inflow cannula. According to some authors [Taghavi S., Ward C., Jayarajan S. N., Gaughan J., Wilson L. M., and Mangi A. A. Surgical Technique Influences HeartMate II Left Ventricular Assist Device Thrombosis. Ann Thorac Surg 2013; 96:1259-65], the angle of the inflow cannula must be greater than 55% to minimize the risk of development thrombosis risk of the HeartMate II device. A deficiency of the above-described technique of placing sutures for implantation of the sewing cuff is twisting of the incision edges inside the left ventricular chamber, which can lead in the future to obstruction of the inflow cannula.
The closest prior art is a method of implantation of the left ventricular mechanical indicated by the developer of the device [HeartMate III Left Ventricular Assist System Instructions for Use. Thoratec Corporation, 2014. Document: 109798.B]. HeartMate III devices are positioned intrapericardially. First the driveline is tunneled, leaving as much of the velour surface of the cable on the inside. A 6-mm coring device is used for perforation of the skin. An anastomosis between the outflow graft and the ascending aorta. The patient is connected to the CPB pump. Select the site for the inflow cannula slightly anterior to the apex and a few centimeters lateral to the anterior to the interventricular artery. Using a scoring punch, cut a round opening in the left ventricle. For sewing the cuff, the techniques of “cut then sew” or “sew then cut” may be used. Place at least 12 horizontal mattress sutures with synthetic pledgets through nearly the entire thickness of the myocardium at a distance of 1.5 cm from the edge of the incision. Sew the sewing cuff and place the device in the left ventricle. Connect the outflow graft to the device. Perform de-airing, activate the HeartMate III device, and switch off the CPB apparatus.
A drawback of this method is the fact that it can be used in the capacity of recommendations, but does not have sufficient clinical information. First of all, the use of the skin coring punch can be a more traumatic method, which can lead to unsatisfactory healing of the wound surface, and the anatomic selection of the site of implantation of the inflow cannula (without check of visualization using a transesophageal echocardiogram), as was described above for implantation of other types of devices. Second, the technique of placing sutures during sewing of the apical sewing cuff is not adequately described. Third, anastomosis between the outflow graft and the and the ascending aorta is created prior to placement of the pump, which subsequently may lead to incorrect length of the graft and technical difficulties in connecting the graft to the device.